Presentations Flashcards
Chest Tubes
Chest tubes/thoracostomy tubes: plastic tubes that are inserted in the = ?
Chest tubes / thoracostomy tubes: plastic tubes that are inserted in the mid-anterior axillary line between the 4th-5th intercostal space
Chest Tubes
Purpose of chest tubes = ?
Chest Tube Purpose = remove air, blood and infectious fluids in the pleural cavity that may be inhibiting lung expansion, and therefore gas exchange.
Chest Tubes
Basic components of chest tubes include = ?
- Collection chamber: collects drainage and monitors amount and nature
- Water seal chamber: a one-way valve that prevents removed substance from returning
- Suction control center: increases the drainage rate, helps re-expand the lung (Normal value: 15-20 cm H2O)
Chest Tubes
Why would a patient need a chest tube?
- Pneumothorax = “collapsed lung”; Collection of air outside of lung but still within pleural cavity
- Penetrating or blunt chest trauma
- Hemothorax = Blood pooling in pleural cavity
- Chylothorax = Lymph pooling in chest cavity
- Emphysema = lung infection or abscess
- Symptomatic pleural effusion = Chest pain, dyspnea, and a dry, non-productive cough. Extra fluid build up from cancer, pneumonia, or heart failure.
- Thorax/cardiac operations = CABG, lobectomy
Chest Tubes
How are chest tubes used?
Chest Tubes
What would prevent/contraindicate PTs from working with these patients effectively?
- Thoracic procedures can cause severe postoperative pain. This restricts shoulder and scapula ROM = frozen shoulder.
- Poor cooperation during sessions because of sleep disruption.
- Before initiating mobilization, PT must ensure stable cardiovascular conditions
Chest Tubes
What are the precautions that must be followed?
- View the patients’ vital signs to identify if they are at risk for an adverse event.
- Want to avoid shoulder abduction and external rotation on the side of the incision to avoid any additional stress at the site of the insertion.
- Be aware of any postural abnormalities and need for correction as they will have a foreign body in their chest cavity.
- The first ambulation/mobilization after placement will require a high level of assistance, likely 2-3 individuals or alternatively using an assistive device, or lift. So be PREPARED and PLAN!
Chest Tubes
What are the PT implications BEFORE treatment?
- Check the insertion site of chest tube for drainage to ensure it is intact, avoid causing patient harm by allowing atmospheric air to gointo thoracic cavity.
- Assess patient response for signs of infection.
- Notify nurse and provider if drastic quality changes (blood, purulence, color).
Chest Tubes
What are the PT implications DURING treatment?
- Ensure continuous draining by gravity (lower than insertion site).
- NEVER lift drain above chest level = Air can enter the pleural cavity if it rises above the water surface level.
- Unless removed from the patient and suction is disconnected, tubing should ALWAYS be secured/clamped to the bed to prevent accidental removal.
- If suction is attached to a wall or no portable machine is available, bedside only exercises have to be considered.
- If a portable suction machine is available, ambulation is possible, but requires use of a trolley.
- Keep tubing free from kinks, occlusions, or dependent loops
- Pain associated with the tube and its insertion site can limit participation in treatment.
Chest Tubes
What about bed mobility, gait training, and therapeutic exercise?
Bed mobility
- Tubing must be kept above chest level.
- Tubing must not be pulled excessively.
Gait training
- If a portable suction machine is available and the patient is medically stable, ambulation is a potential intervention use of trolley.
- Transfer from wall suction to portable requires nurse or physician.
Therapeutic exercise
- If a portable machine is not available or the suction must come from the wall, EOB exercises or exercises in bed must be utilized.
- Type of exercise is limited when a large device is required to get out of bed.
Chest Tubes
PT rehab protocol goals include?
Chest Tubes
Summary - Importance of PT and pts with chest tubes.
Importance of PT
- Prevents formation of adhesions between the pleural layers
- Aims to regain full lung expansion or improve ventilation
- Increases exercise tolerance capacity
- Maintains joint mobility
- Increases overall well-being while in an acute setting and focuses on return to ADLs and health
- Pain management
Mechanical Ventilators
Mechanical Ventilators:
- What = ?
- When = ?
- Where = ?
- What = Machines that act as bellows to move air in and out of your lungs
- When = When patients cannot breathe independently.
- Where = Hospitals, ambulances, nursing homes, living environment
Mechanical Ventilators
Three kinds of mechanical ventilators are
Volume-Cycled Ventilator:
- A form of positive pressure ventilation.
- Tidal volume is set, and lung pressure remains variable.
- Airway pressure is monitored to ensure safety.
Pressure Cycled Ventilator:
- A form of positive pressure ventilation.
- Inspiratory pressure is set, and tidal volume remains variable.
- Tidal volume is monitored to ensure proper respiration.
Negative Pressure Ventilator:
- A device surrounding the trunk exposes the chest cavity to sub-atmospheric pressure during inspiration, which draws air into the lungs.
- For expiration, the pressure is increased to atmospheric or above atmospheric to expel air from the
lungs. - Utilized most frequently in the 1950s with the emergence of the “Iron
Lung.” Today, a device called a Cuirass is used to form around the patient’s chest tightly and more comfortably.
Mechanical Ventilators
A ventilator is a machine that = ?
A ventilator is a machine that partially or completely supports a patient’s lung function.
Mechanical Ventilators
Ventilators deliver = ?
Ventilators:
- deliver oxygen to the lungs
- remove carbon dioxide from the lungs, and
- provides pressure to prevent the
alveoli from collapsing
Mechanical Ventilators
Ventilators are used to decrease = ?
Ventilators are used to:
- decrease the amount of energy severely ill patients use on breathing, or
- to breathe for patients who are unable to breathe on their own due to injury or illness
Mechanical Ventilators
Invasive Mechanical Ventilation (2)
vs.
Noninvasive Ventilation (3)
Invasive Mechanical Ventilation:
- Endotracheal Intubation: A tube is inserted into the airway via the nose or mouth
- Tracheostomy: A tube is inserted through a hole made into the airway
Noninvasive Ventilation:
- Continuous Positive Airway Pressure (CPAP): Delivers constant, steady air pressure
- Autotitrating Positive Airway Pressure (APAP): Changes air pressure based on the breathing pattern
- Bilevel Positive Airway Pressure (BiPAP): Delivers different air pressures for inhalation and exhalation
Mechanical Ventilators
Why are ventilators important?
What are some specific conditions that require use?
- Mechanical ventilators are used to help patients unable to breathe on their own.
- It helps patients increase their oxygen level and prevent their lungs from collapsing.
There are some specific conditions that might require patients to need mechanical ventilations such as:
- Acute respiratory distress syndrome (ARDS)
- Pneumonia
- Chronic obstructive pulmonary disease (COPD)
- Stroke
- Traumatic brain injury
Mechanical Ventilators
Contraindications / Precautions for ventilators include = ?
- No absolute contraindications except if the pt decides to abstain from and artificial life saving measures.
- The only relative contraindication of mechanical ventilation is if non-invasive ventilation is expected to clear up the need for mechanical ventilation.
- Consult with interprofessional team to discuss goals of therapy.
- Assess for pain, anxiety and sedation level.
- Check Ventilator settings before treatment and monitor during treatment.
- Check vital signs, pulse oximetry and last ABGs,if there was a change notify nursing.
Mechanical Ventilators
Implications to PT Treatment
Mobility Transfers
- Review patient’s previous mobility status and current vital signs to ensure limitations of mobilization
- Cardiovascular limitations such as HR <40 or >130, active bleeding, or cardiac status of active cardiac ischema.
- Limitations for respiratory vitals are having a respiratory rate <5 or >40, <88% SPO2, and if ventilator is having issues or is currently troubleshooting.
Gait Training
- Observable implications would be how efficiently the mechanical ventilator transitions with the patient.
- Physical Therapist limitation to safely guard patient while ensuring no risk of mechanical issues
- Limited support from staff.
Therapeutic Treatment
- Neurological limitations involving the patient’s status if they are combative, distressed or agitated.
- Accessibility to appropriate equipment
- Unstable spinal cord injury or vertebral fracture
Mechanical Ventilators
Ventilator Summary
Summary
- Description = Volume-cycled, pressure-cycled, and negative pressure ventilation
- Uses = Deliver oxygen, remove carbon dioxide, and reduce energy costs of respiration, AND Invasive and non-invasive ventilation
Why mechanical ventilation may be necessary:
- Pneumonia, CVA, TBI, COPD
- Contraindications and precautions
- Patients with a DNR order
- Continuously monitor vital signs and ventilator settings to confirm patients’ health and safety
- Implications to PT treatment = Mobility transfers, gait training, and therapeutic treatment
Dialysis Treatment
Dialysis is necessary when = ?
Conditions that require dialysis = ?
- Dialysis is necessary when the kidneys are unable to remove waste and extra fluid from the blood.
- If the kidneys are not functioning properly, waste can build up to unsafe levels and cause seizures, coma, and eventually death.
Conditions that require dialysis:
- End-stage renal disease (ESRD)
- Traumatic kidney injury (i.e. car crash)
- Poison/toxic ingestion
Dialysis Treatment
Types of Dialysis = ?
Hemodialysis (most common):
- A needle is placed in the patient’s arm, and a tube is used to connect the needle to an external machine.
- Blood passes from the patient, through the tube, and to the machine to filter it. It is then passed through the tube again, back to the patient.
- This process takes around 4 hours and is done around 3 times a week.
Continuous renal replacement therapy (CRRT):
- Similar to hemodialysis but is continuously filtering blood 24/7.
- Less stress to the heart with this method.
Peritoneal dialysis:
- Instead of a machine, an incision is made near the belly button, and a catheter is inserted into the peritoneal cavity.
- Fluid is pumped through the tube into the cavity. Waste is drawn into this fluid, and the fluid is drawn back out of the body into a bag.
Catheters
What are the 5 types of catheters?
- Suprapubic: Surgically inserted into the bladder through an incision in the abdomen.
- Indwelling: Through the urethra
- Condom / Purewick: External
- Epidural (Pain): Inserted in the spine
- Pain pump (Pain): Can be inserted close to surgical area.
Oxygen
Nasal cannula = ?
- It is a thin, flexible tube that goes around your head and into your nose that delivers additional oxygen
- There are two prongs that go inside your nostrils and deliver the oxygen
- The nasal cannula is attached to an oxygen source (ex. Oxygen tank or container)
- Medium setting- 2 l/min
- High setting- 4 l/min
Oxygen
What is this ?
Oronasal Mask
- Mask covering the nose and mouth that supplies air.
- Most commonly used for continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) and acute respiratory failure.
- Oronasal mask delivers higher ventilation pressures, permits mouth breathing, and reduce mouth leaks.
Contraindications & Precautions:
- High overall leak and lower adherence
- High therapeutic pressure
- High risk of aspiration
- High residual AHI
- Pressure ulcers
- Congestion and dry nose
- Claustrophobia
Implications to PT:
* Ensure the mask is not causing any discomfort and being aware of the where the tubes/lines are during activity.
Oxygen
? = Is inserted into a single nostril and travels down into the patient’s nasopharynx while delivering a steady flow of oxygen.
Nasal Catheter
Contraindications and Precautions:
- Drying of the mucous membranes inside the nostril.
- Nasal trauma
- Nasal malformation
- Not used when there is a nasal mucosal tear because it could lead to surgical emphysema (air in the deepest layer of the skin).
Implications for PT:
- Ensure that the nasal catheter is not causing discomfort for the patient or has shifted.
Oxygen
Oxygen Face Tent
Description:
- An oxygen face tent is a mask that that fits under the patient’s chin and encircles their face. There is no seal around the nose which gives a shield like appearance.
- The tent directs the oxygen upward and uses a cold nebulizer.
Uses:
- Oxygen and humidification
Why:
- The patient may not be able to tolerate a tight fitting mask.
Contraindications:
- Patients with COPD
Precautions:
- Fire Hazard
Implications:
- Although the levels of oxygen are controlled, it is difficult to achieve high levels of oxygen concentration, in the event this is needed for a patient.
- It is also difficult to estimate the amount of oxygen being released due to how close it is to the patient’s face.
- As a therapist, you may need to titrate SpO2 to the appropriate level.
Oxygen
What is this ?
Tracheostomy Mask
Description & Uses:
- A tracheostomy mask is a removable piece of equipment that provides oxygen and flow specifically for patients with a tracheostomy.
- The mask itself sits over a dressing and another piece of equipment called a trach which is inserted into the actual tracheostomy site.
- Tracheostomy masks are typically used in acute settings for patients with illnesses that reduce their oxygen saturation.
Why:
- A tracheostomy mask is necessary for individuals who have a trach and need more oxygen support than just being on room air with a heat moisture exchanger.
- A trach mask helps with oxygenation, however it doesn’t provide ventilation. For this reason, some tracheostomy patients might be trach ventilator dependent.
Oxygen
What is this ?
- The Airvo is a stand-alone or integrated device that is used to deliver Optiflow Nasal High Flow (NHF) therapy to acute respiratory failure patients.
- NHF therapy is a treatment that delivers respiratory support by providing heated, humidified air and oxygen at flow rates.
- This is used when traditional oxygen therapy is not working.
Contradictions:
- Include Multi-organ failure, trauma/surgery to nasopharynx and base skull, and congenital abnormality of nasopharynx.
Precautions:
- Hot plate included in device so there is a large burn warning, prevention of water bag becoming empty as this will cause the unit to overheat.
